JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
2023 Summer Camp Registration
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Grade (Fall 2023)
*
Your answer
Home Address (Street #, Street Name, City, State, Zip)
*
Your answer
Student's School
*
Your answer
Student's T-Shirt Size
*
XXS
XS
S
M
L
XL
XXL
XXXL
Other:
Summer Camp:
*
Scrub Life (June 13-15)
What's on the Menu (June 20-22)
Starting at Square 1 - Week 1 (July 17-20)
Starting at Square 1- Week 2 (July 24-27)
Find Your Future (August 1-3)
Photo/Video Release: I give my permission for MCESA and partners to take pictures, video, or audio of my child/ward for future publicity purposes related to the event.
*
Yes
No
Is the participant covered by health insurance?
*
Yes
No
If yes, name of insurance provider and policy group number.
*
Your answer
Is the Midland County ESA authorized to approve emergency medical treatment?
*
Yes
No
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Parent/Guardian's Phone Number for Emergency Contact
*
Your answer
Parent/Guardian's Email Address
Your answer
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
*
Your answer
PayPal Link:
https://paypal.me/CTEMCESA?locale.x=en_US
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Midland County Educational Service Agency.
Report Abuse
Forms
